Selwyn Care Limited - Brian Wells Lodge

Selwyn Care Limited - Brian Wells Lodge

Introduction

This report records the results of a Certification Audit ofa provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).

The audit has been conducted byHealth and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.

The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).

You can view a full copy of the standards on the Ministry of Health’s website by clicking here.

The specifics of this audit included:

Legal entity:Selwyn Care Limited

Premises audited:Brian Wells Lodge

Services audited:Dementia care

Dates of audit:Start date: 9 April 2014End date: 9 April 2014

Proposed changes to current services (if any):None

Total beds occupied across all premises included in the audit on the first day of the audit:14

Executive summary of the audit

Introduction

This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:

• consumer rights
• organisational management
• continuum of service delivery (the provision of services)
• safe and appropriate environment
• restraint minimisation and safe practice
• infection prevention and control.

As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome areas. The following table provides a key to how the indicators are arrived at.

Key to the indicators

Indicator / Description / Definition
Includes commendable elements above the required levels of performance / All standards applicable to this service fully attained with some standards exceeded
No short falls / Standards applicable to this service fully attained
Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity / Some standards applicable to this service partially attained and of low risk
A number of shortfalls that require specific action to address / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk
Major shortfalls, significant action is needed to achieve the required levels of performance / Some standards applicable to this service unattained and of moderate or high risk

General overview of the audit

Brian Wells is owned and operated by the Selwyn Foundation and provides care for up to 16 residents requiring rest home (dementia) level care. On the day of the audit there were 14 residents. The assistant village manager and assistant care lead are well qualified and experienced for the roles. Relatives and the general practitioner (GP) interviewed spoke positively about the service provided.

The audit was conducted against the relevant Health and Disability standards and the contract with the District Health Board. The audit process included a review of policies and procedures; the review of resident’s and staff files, observations and interviews with relatives, staff and management.

This audit has identified no areas for improvement. The standard has been exceeded around quality and risk management processes, incident management and staff training.

Consumer rights

Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. / Standards applicable to this service fully attained.

The staff at Brian Wells ensures that care is provided in a way that focuses on the individual, values residents' autonomy and maintains their privacy and choice. The service functions in a way that complies with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Information about the Code and services is easily accessible to residents and families. Information on informed consent is included in the admission agreement and discussed with residents (where able) and relatives. Informed consent processes are followed and residents' clinical files reviewed evidence informed consent and advanced directives are documented. Complaints and concerns have been managed and a complaints register is maintained.

Organisational management

Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. / All standards applicable to this service fully attained with some standards exceeded.

Brian Wells has a quality and risk management system in place that is implemented and monitored, which generates improvements in practice and service delivery. Key components of the quality management system link to relevant facility meetings. The service is active in analysing data with recent evidence of benchmarking outcomes with other similar aged care facilities. Corrective actions are identified and implemented. Health and safety policies, systems and processes are implemented to manage risk. Incidents and accidents are reported and appropriately managed. There is a comprehensive orientation programme that provides new staff with relevant and specific information for safe work practice. The in-service education programme covers relevant aspects of care and support. The staffing levels provide sufficient and appropriate coverage for the effective delivery of care and support. Staffing is based on the occupancy and acuity of the residents.

Continuum of service delivery

Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. / Standards applicable to this service fully attained.

The service has a documented assessment process and resident’s needs are assessed prior to entry. There is an information pack available for residents/families/whānau at entry that includes information specific to dementia care.
Assessments, care plans and evaluations are completed by the registered nurse. Residents (as appropriate), relatives/whanau were involved in planning and evaluating care. Service delivery plans demonstrate service integration and are individualised to meet the resident’s needs. Care plans are evaluated six monthly or more frequently when clinically indicated. Acute care plans are available for use for short term needs. The service facilitates access to other medical and non-medical services.
The on-site diversional therapist oversees the seven day week programme focused on meaningful activities that meets the individual abilities and recreational preferences. The individual care plans include activities over a 24 hour period. Caregivers provide activities and the service has initiated employment of an intern.

The service medication management policies and procedures follow recognised standards and guidelines for safe medicine management practice. The general practitioner reviews medication charts three monthly.
Meals are prepared and cooked off-site by contractors. Individual and special dietary needs are accommodated. There are nutritious snacks available 24 hours per day.

Safe and appropriate environment

Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. / Standards applicable to this service fully attained.

The building holds a current warrant of fitness. A maintenance manager oversees the reactive and planned maintenance. Hot water temperatures are monitored. Residents are able to bring their own possessions and adorn their room as desired. The facility is spacious with communal areas that are easily accessible. There are large grounds and gardens that are safe and secure. Seating and shade is available. Chemicals are stored safely throughout the facility. There is adequate heating, ventilation and natural light in bedrooms and communal areas. The facility was clean and well presented.

Restraint minimisation and safe practice

Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. / Standards applicable to this service fully attained.

Brian Wells continues to provide a restraint free environment. There is a restraint policy that included comprehensive restraint procedures and aligns with the standards. There are no residents using enablers.

Infection prevention and control

Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. / Standards applicable to this service fully attained.

Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. Infection control education is provided to all staff as part of their orientation and also as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Results of surveillance are acted upon, evaluated and reported to relevant personnel.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Attainment Rating / Continuous Improvement
(CI) / Fully Attained
(FA) / Partially Attained Negligible Risk
(PA Negligible) / Partially Attained Low Risk
(PA Low) / Partially Attained Moderate Risk
(PA Moderate) / Partially Attained High Risk
(PA High) / Partially Attained Critical Risk
(PA Critical)
Standards / 2 / 43 / 0 / 0 / 0 / 0 / 0
Criteria / 3 / 90 / 0 / 0 / 0 / 0 / 0
Attainment Rating / Unattained Negligible Risk
(UA Negligible) / Unattained Low Risk
(UA Low) / Unattained Moderate Risk
(UA Moderate) / Unattained High Risk
(UA High) / Unattained Critical Risk
(UA Critical)
Standards / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 0 / 0 / 0 / 0

Attainment against the Health and Disability Services Standards

The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit.

Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section.

For more information on the standards, please click here.

For more information on the different types of audits and what they cover please click here.

Standard with desired outcome / Attainment Rating / Audit Evidence
Standard 1.1.1: Consumer Rights During Service Delivery
Consumers receive services in accordance with consumer rights legislation. / FA / Discussions with staff (two caregivers, the assistant care lead and one registered nurse) confirmed their familiarity with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers’ Rights (the Code). Five relatives were interviewed and confirmed the services being provided are in line with the Code.
Standard 1.1.10: Informed Consent
Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. / FA / The informed consent policy includes responsibilities and procedures for staff. Informed consent information is provided to family/whanau on admission. Written general consent has been signed by the family in all resident files sampled. Two caregivers and the registered nurse (RN) interviewed were able to describe resident choice and informed consent (as appropriate) when delivering resident cares.
Files include a resuscitation decision form. The GP discusses resuscitation with the family/whanau where the resident is deemed incompetent to make a decision.
D3.1.d: Discussion with five family members identifies that the service actively involves them in decisions that affect their relative’s lives.
D13.1: There were five signed admission agreements sampled.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Contact numbers for advocacy services are included in the policy, in the resident information folder and in advocacy pamphlets that are available at Brian Wells. Discussions with relatives identified that the service provides opportunities for the family/EPOA to be involved in decisions.
Standard 1.1.12: Links With Family/Whānau And Other Community Resources
Consumers are able to maintain links with their family/whānau and their community. / FA / Relatives confirmed that visiting can occur at any time. Key people involved in the resident’s life have been documented in the care plans. Relatives verified that residents have been supported and encouraged to remain involved in the community. Entertainers have been invited to perform at the service.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / A complaints policy and procedures have been implemented and residents and their family/whanau have been provided with information on admission. Complaint forms are available at the service. Staff are aware of the complaints process and to whom they should direct complaints. A complaints folder has been maintained. Three complaints were received in 2014. Systems and processes have been in place and documented to confirm that all complaints received are managed and resolved appropriately. Family members advised that they are aware of the complaints procedure and how to access forms.
E4.1biii: There is written information on the service philosophy and practices particular to the dementia unit included in the information pack.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / The service provides information to residents that include the Code, complaints and advocacy. Information is given to the family or the enduring power of attorney (EPOA) to read to and/or discuss with the resident. Relatives interviewed identified they are well-informed about the code of rights. The family survey provides the opportunity to raise concerns. Advocacy and code of rights information is included in the information pack.
Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect
Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. / FA / Staff interviewed were able to describe the procedures for maintaining confidentiality of resident records, resident’s privacy and dignity. House rules and a code of conduct are signed by staff at commencement of employment.
Church services are held weekly and resident files include cultural and spiritual values. Contact details of spiritual/religious advisors are available to staff. Relatives interviewed reported that residents are able to choose to engage in activities and access community resources. There is an elder abuse and neglect policy and staff education and training on abuse and neglect has been provided.
E4.1a The five family members interviewed stated that their family member was welcomed into the unit and personal pictures were put up to assist them to orientate to their new environment.
Standard 1.1.4: Recognition Of Māori Values And Beliefs
Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. / FA / The service has a Maori heath plan and policies that include cultural safety and awareness. Discussions with staff confirmed their understanding of the different cultural needs of residents and their whānau. There are currently no residents at Brian Wells who identify as Maori. The service has established links with local Maori and an organisational Kaumatua. Staff confirmed they are aware of the need to respond appropriately to maintain cultural safety.
Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs